Thursday, September 3, 2015

#ILookLikeASurgeon: Breaking the silence on hard topics

Surgical Families

by Heather Logghe, MD

With over 100 million impressions on Twitter, the #ILookLikeASurgeon movement demonstrates the diverse faces of surgery. The #ILookLikeASurgeon Twitter feed also makes it clear that the topic of family is at the forefront of many surgeons’ minds.

In 2015, it is imperative that surgical culture embrace an inclusive and progressive definition of family. In order to define family this way, we need only look at the broader community of which we are a part. So far, we have heard from Dr. Chris Porter, who at first glance appears the stereotypic surgeon--white, male, forthright, confident. But beneath the surface he struggles to balance the responsibilities, pride, and joy of being a single parent with his passion for and dedication to his surgical career and patients. We've also heard from Dr. Elinore Kaufman, a queer resident-in-training, who shared her experience as a mom whose female partner carried their child. Family transcends gender and orientation.

Luke Selby, MD and his son

Balancing career and family commitments is no longer a “women’s” issue. Male and female residents ask senior colleagues for advice on work-life balance in equal numbers. Furthermore, male surgeons have felt progressively more comfortable expressing the distress resulting from not being allowed time to witness and celebrate their child's birth or to help care for their infants. Fathers and mothers both agonize over when to have children. Both partners grieve when one suffers a miscarriage. Even single, childless surgeons can face family obligations when caring for aging parents. These modern voices offer a perspective that is vital to enriching our discussion about family in surgery.

Pregnancy Then and Now

I have been passionate about this topic since hitting the interview trail for residency 6 months pregnant. As a medical student I heard the legend of a well-known woman surgeon continuing to suture through contractions as she went into labor. It was an unspoken but clear precedent for others* who might become pregnant. The part of this legend that is frequently omitted is that these contractions led to premature labor, resulting in the first weeks of her child’s life being spent in the NICU. As women surgeons, we take pride in our strength, but sometimes to a fault. It worries me that appearing “tough” and “committed” in the OR can be in direct conflict with our own health and that of our offspring. One resident begged a colleague to place a foley catheter in her so she could operate without bathroom breaks. Her co-resident acquiesced and she went into labor and delivered the next day, a month early. These stories send the message that accommodations for pregnancy are unwelcome, if not blatantly rejected.

When I learned I would be pregnant during the residency application process, I consulted multiple mentors on how to address this “issue” during interviews. I was advised by two of my most respected female mentors not to mention a word about the pregnancy, despite the fact that I would be 6 months pregnant and likely showing. While this recommendation was evidence-based, I did not feel comfortable following it. The sacrifices of women who came before me made it possible for me to question this status quo. I have the utmost respect for the women who did not have the option of publicly discussing their pregnancies and the inherent challenges, likely out of a realistic fear that it would jeopardize their careers. I am happy to report that I received no negative comments on the interview trail. I’ll never know what role my pregnancy played in the match, but I ended up with a prelim position.

My husband and I had timed the pregnancy to ensure that pregnancy did not interfere with training. Little did I know that the impact of pregnancy on one’s body can last long after the labor pains are over. I’ll never forget when six months after giving birth during intern year, I sprinted a few steps to the ER, and on the fifth step I felt my cystocele protrude, with my bladder literally falling out of my body. Fortunately the women’s clinic was housed within the hospital, and the female nurse practitioner on our team allowed me time to step away. I remain grateful to the administrative assistant who recognized the fear and concern on my face and convinced one of the gynecologists to see me without an appointment. In 15 minutes I was back on the wards with a pessary in place.

The Future of Pregnancy in Surgery

Throughout #ILookLikeASurgeon, we have heard stories and seen pictures boasting women operating with nine month baby bumps, accompanied by encouraging hashtags such as #RoleModel and #MakingItWork. While this may be perfectly safe and appropriate for some women and their pregnancies, it is not a healthy model for all pregnancies or all surgeons. Studies** show that surgeons have poorer pregnancy and birth outcomes compared to average American women. Clearly the current approach is not working. It behooves us to acknowledge that growing a human being takes significant energy and an undeniable toll on women’s bodies.

At the top of La Honda at 38 weeks

Achieving healthy pregnancies and newborns should not require women to avoid becoming surgeons or surgeons to forgo pregnancy. The cultural and professional expectations we place on women both in the operating room and as life-giving human beings must account for the hard work and dedication it takes to be successful at both surgery and parenthood. Neither is accomplished without community and institutional structures of support.

As physicians, and as surgeons in particular, we rely on our bodies to be vessels of healing. Taking care of ourselves, such as with my cystocele and visiting the doctor for a legitimate medical emergency, should not require luck or fortuitous circumstance. While the pessary served as an effective “band-aid,” it is only now, during my research years, that I have time to return to a physical therapist for pelvic floor rehabilitation. After the traumatic loss of one of its residents, Stanford launched an innovative “Balance in Life” program that facilitates regular primary care and dental visits. They also required interval psychologic evaluation to identify and mitigate burnout. Other programs shouldn’t wait for a resident death to actively create an environment that promotes the health of its residents.

My Story

Ride for World Health 2006

The challenge of family planning that has touched me personally is how to create a professional work culture that fosters healthy pregnancies, labors, and newborns for surgeons and surgeons’ partners. Before I delve in, I’d like to disclose that I am no stranger to physical pain and endurance. I have trained in Brazilian Jiu Jitsu, completed multiple marathons including two Ironman Triathlons, and cycled across the country (SF to DC). Yet, I was shocked by the heavy physical toll the first trimester took on my body. Of course, there does exist the rare, lucky individual who sails through pregnancy, but we cannot predict or expect this. Even my “healthy” pregnancy was not without significant challenges.

My husband and I had originally hoped I would become pregnant during my 4th year of medical school. When that didn’t happen, I decided to take a year between medical school and residency to have a child. It is notable that we conceived the first month after graduation. I cannot help but conjecture that the stress of clinical rotations and the competitive nature of medical school inhibited our ability to conceive.

Brazilian Jiu Jitsu

I was alerted to my pregnancy when I had cardiac pain while cycling up a mountain days before my period was due. Thus the physical impact was evident within days of conception. In addition to seeing stars every time I stood up and frequent urination, I also suffered severe shortness of breath and debilitating low back pain requiring chiropractic care. Mind you this was all during the first trimester, before I had gained a single pound.

The low back pain shocked me. I was only 10 weeks into my pregnancy when I noticed shooting pains upon shifting positions in my seat. It literally hurt to move. I called my midwife based on the sheer terror that I would not be able to move for the remainder of my pregnancy. She hypothesized that I had had a tailbone injury years earlier (true) that was somehow reactivated by the hormonally-driven ligamentous and muscular relaxation of pregnancy. After Googling possible solutions, I decided to seek care from a chiropractor, which made a huge difference. Ultimately I found that once or twice weekly deep tissue massage treatments (“torture” sessions in my opinion) enabled me to continue the active lifestyle to which I was accustomed.

I also found an online group of pregnant “mommas” who ran, which was invaluable. It was one of the internet “mommy boards” that reassured me that my shortness of breath was normal, encouraging me to continue running throughout the first and much of the second trimester. Around week 25, I began to notice a fullness in my pelvis, prompting me to cut back on my running. Soon after, the feeling morphed into the peculiar sensation of a tampon falling out. At that point I decided to inspect things, only to realize that I had developed a full blown cystocele! In addition to once or twice weekly chiropractic care, I now added weekly sessions of specialized physical therapy to keep my insides, well, inside! I remain eternally grateful that I was without clinical responsibilities at the time, allowing me time to attend deep tissue massage and physical therapy appointments in addition to normal prenatal care.

Proud parents

My saving grace throughout this was that while riding my bike, aside from some significant huffing and puffing, I barely felt pregnant! I continued cycling throughout my pregnancy, completing a century ride at 16 weeks. I even tried mountain biking at 22 weeks, but after two crashes and a concussion, decided it maybe wasn’t the best idea. Up until the day I delivered I was able to cycle mountains and complete rides of up to 40 miles. The day I didn’t feel “up to it” turned out to be the day I went into labor.

In the end, I delivered a healthy, 5 lb 12 oz baby girl, full term, but 10 days early, just as my “Exercising Through Pregnancy” book predicted. I had three months with her before starting residency and was able to pump and continue breastfeeding still today. It’s hard to imagine residency without her :-)

Share Your Experience

Now I’ve shared my story. To realize how #ILookLikeASurgeon can transform our profession, I encourage you to share yours. These may not be pregnancy or infertility stories, but also stories about how we create and support families; the challenges, barriers, and creative solutions we can replicate. Only through an open and authentic conversation, with participation from all genders, can we set the foundation to create lasting solutions. You can share your story through your own personal blog, a guest blog post on Allies For Health, or even a simple email or direct message. Now is the time to finally speak up and let your voice be heard.

*Given there are transgender and gender nonconforming people who bear children, I have intentionally aimed to use gender-neutral language in reference to pregnancy. Special thank you to Dr. Elinore Kaufman for this recommendation.